agsp-30 - application for registration as a medical ... · pdf fileagsp-30 agsp-303...

*AGSP-301*

Application for specialist registration For applicants who do not hold general registration

Profession: Medical

AGSP-30

Part 7 Division 6 of the Health Practitioner Regulation National Law (the National Law)

Effective from: 18 March 2014 of 13

This form is to be used by international medical graduates who do not hold general registration and who are applying to practise within a medical specialty.It is important that you refer to the Medical Board of Australia’s (the Board) registration standards, codes and guidelines before completing this application. Registration standards, codes and guidelines can be found at www.medicalboard.gov.au

This application will not be considered unless it is complete and all supporting documentation has been provided. Supporting documentation must be certified in accordance with the Australian Health Practitioner Regulation Agency (AHPRA) guidelines; see Certifying documents in the Information and definitions section of this form.

Privacy and confidentialityThe information collected in this form is authorised or required under the National Law for the purposes of determining an applicant’s eligibility for registration. Information supplied in this form may be provided to other people or agencies as specified in the National Law. Failure to provide some or all of the information requested may prevent you being registered. AHPRA’s Privacy policy explains how your personal information will be stored, handled and used. The privacy policy outlines how you can access information AHPRA holds about you, and how you may make a complaint if you feel your privacy has been breached by AHPRA. This document can be accessed at www.ahpra.gov.au/privacy

Symbols in this form Additional information

Provides specific information about a question or section of the form.

Attention Highlights important information about the form.

Attach document(s) to this form Processing cannot occur until all required documents are received.

Signature required Requests appropriate parties to sign the form where indicated.

Mail document(s) directly to AHPRA Requires delivery of documents by an organisation or the applicant.

Completing this form• Read and complete all questions.

• Ensure that all pages and required attachments are returned to AHPRA.

• Use a black or blue pen only.

• Print clearly in B L OC K L E TTE RS• Place X in all applicable boxes:

• DO NOT send original documents unless specified.

Do not use staples or glue, or affix sticky notes to your application. Please ensure all supporting documents are on A4 size paper.

SECTION A: Personal details

The information items in this section of the application marked with an asterisk (*) will appear on the public register.

1. What is your name and date of birth?

If you have ever been formally known by another name, or you are providing documents in another name, you must attach proof of your name change.

For more information, see Change of name in the Information and definitions section of this form.

Title*

MR MRS MISS MS DR OTHER SPECIFY

Family name*

First given name*

Middle name(s)*

Previous names known by (e.g. maiden name)

Date of birth D D / M M / Y Y Y Y

*AGSP-302*AGSP-30


2. What are your birth and personal details? Country of birth

City/Suburb/Town of birth

State/Territory of birth (if within Australia)

VIC NSW QLD SA WA NT TAS ACT

Sex* MALE FEMALE

Languages spoken other than English (optional)*

SECTION B: Proof of identity

You must provide proof of your identity with this application

The minimum requirements for overseas applicants, or those who have recently arrived in Australia, can be found in the AHPRA Proof of identity requirements document under the heading What special circumstances apply to overseas applicants or applicants who have recently arrived in Australia? This document is available at www.ahpra.gov.au/identity

• You must provide evidence from category A, B, and C.

• You must only use each document once.

• If your evidence from category C or B does not include your residential address, you must also provide evidence from category D.

Please indicate on the chart below which piece of evidence you are submitting for each category and attach the certified or notarised copies of documents to your application.

3. Which documents from each category will you provide for proof of identity?

The documents provided must meet the following criteria:

•Atleastone document must be in the applicant’s current name.

•YourcategoryBdocumentmust have a recent photo.

•Alldocumentsmust be officially translated into English. For documents translated in Australia, the translator must be accredited by NAATI – see www.naati.com.au For documents translated overseas, see www.fit-ift.org for a list of authorities who provide certified translations. Please refer to Translating documents at www.ahpra.gov.au/translate for further information.

•Australianbirthcertificate extracts are not accepted.

•Ifusingyourpassport,acertifiedcopy of the identity information page (the photo page) must be provided.

•Alldocumentsmust be true certified or notarised copies of the original. See Certifying documents in the Information and definitions section of this form for more information.

Choose proof of identity documents to submit: (A document may only be used once for any category)

DocumentsCategory used:

DocumentsCategory used:

A B C A B C

Australian passport Medicare card NA NA

Overseas passport with current Aust. visa PAYG payment summary NA NA

Australian birth certificate NA Motor vehicle registration NA NA

Current Australian visa NA Financial institution statement NA NA

Australian Armed Services papers NA Taxation assessment notice NA NA

Travel documents with Aust. visa NA Health insurance card NA NA

Australian citizenship certificate NA Pension card NA NA

Australian driver licence NA Category D documents

Working with children check card NAA document from Category D is only required if your Category B or C document does not provide evidence of your residential address.

Firearm or shooters licence NA

Student ID card NA

International driver licence NA I have used a Category B or C document that has my current residential addressProof of age card NA

Change of name certificate NA NA Mortgage papers

Australian marriage certificate NA NA Rate notices

Australian divorce papers NA NA Lease or tenancy agreement

Board registration certificate NA NA Utility account

Bank acct. details – credit or ATM card NA NA Electoral enrolment card

You must attach a certified copy of all proof of identity documents that you have indicated above.

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SECTION C: Contact information

4. What are your contact details?Provide your current contact details below – place an next to your preferred contact phone number.

Business hours

After hours

Mobile

Email

5. What is your residential address?

If you are not currently practising, or are not practising the profession predominantly at one address:

• your residential address will be recognised as your principal place of practice, and

• the information items marked with an asterisk (*) will appear on the public register as your principal place of practice.

Refer to the question below for the definition of principal place of practice.

Residential address cannot be a PO Box.

Site/building and/or position/department (if applicable)

Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town*

State (e.g. VIC, NSW, ACT)/International province* Postcode/ZIP*

Country (if other than Australia)

6. Is the address of your principal place of practice the same as your residential address?

Principal place of practice for a registered health practitioner is:

• the address at which you predominantly practise the profession, or

• your principal place of residence, if you are not practising the profession or are not practising the profession predominantly at one address.

Principal place of practice cannot be a PO Box.

The information items marked with an asterisk (*) will appear on the public register.

YES NO Provide your Australian principal place of practice below


Address (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET)

City/Suburb/Town*

State* (e.g. VIC, NSW, ACT) Postcode*

*AGSP-304*AGSP-30


7. What is your mailing address? Your mailing address is used for postal correspondence

My residential address

My principal place of practice

Other (Provide your mailing address below)


Address/PO Box (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State (e.g. VIC, NSW, ACT)/International province Postcode/ZIP

Country (if other than Australia)

SECTION D: Qualification for the profession

In accordance with section 57 of the National Law, to be eligible for specialist registration you must be qualified for specialist registration in the health profession. Section 58 of the National Law states that to be qualified you must hold either:(a) an approved qualification for the specialty(b) another qualification that the National Board established for the health profession considers to be substantially equivalent, or based

on similar competencies, to an approved qualification for the specialty(c) a qualification, not referred to in (a) or (b), relevant to the health profession AND have successfully completed an examination or

other assessment required by the National Board for the purpose of general registration in the specialty, or(d) a qualification, not referred to in (a) or (b), that under the National Law, or a corresponding prior Act, qualified you for specialist

registration (however described) in the specialty and you were previously registered on the basis of holding that qualification for the specialty.

8. What are the details of your relevant qualifications?

The Board maintains a list of approved specialties, fields of specialty practice and related specialist titles. The complete list of approved specialties can be found in the List of specialties, fields of specialty practice and related specialist titles registration standard on the Board’s website www.medicalboard.gov.au

Specialties outside of the approved list will not meet the eligibility requirements for specialist registration.

Primary specialist qualification

Title of qualification

Title of medical specialty

Field of specialty practice (if applicable)

Name of specialist college recognising specialist qualifications

Date of recognition

M M / Y Y Y Y

You must attach certified evidence of either: • a Board-approved Australian/Australasian College Fellowship, or • eligibility for A Board approved Australian/Australasian College Fellowship.

For further information see the Board’s registration standard for specialist registration at www.medicalboard.gov.au\registration standards

*AGSP-305*AGSP-30


Additional qualification and examinations/assessments


Name of institution (University/College/Examining body)

Country

Start date Completion date

M M / Y Y Y Y M M / Y Y Y Y

You must attach a certified copy of your original academic transcript and testimony or certificate that indicates completion of the qualification mentioned in this form.

Additional qualification and examinations/assessments


Name of institution (University/College/Examining body)

Country



You must attach a certified copy of your original academic transcript and testimony or certificate that indicates completion of the qualification mentioned in this form.

Attach a separate sheet if all your qualification details do not fit in the space provided.

SECTION E: Primary source verification of qualifications

For your application to be considered, you must have applied, or previously applied, to the Australian Medical Council (AMC) to have your qualifications verified. The AMC will verify your qualifications through the International Credentials Service of the Educational Commission for Foreign Medical Graduates of the United States (EICS verification). The verification will be sent directly to the Board. For further information visit www.amc.org.au

9. Have you applied to the AMC to have your qualifications verified?

YES NO

Provide your AMC candidate number below

AMC candidate number

SECTION F: Internship and other supervised practice details

All applicants must provide details of an internship, or comparable, if applying for initial registration in Australia.

10. What are the details of your internship (or comparable)?

Name of institution

Country



You must attach evidence of completion of your internship or comparable if you are applying for initial registration in Australia.

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SECTION G: Registration history

11. What is your health practitioner registration history?

The Board requires a Certificate of Registration Status or Certificate of Good Standing from every jurisdiction outside of Australia in which you are currently, or have previously been, registered as a health practitioner during the past 10 years.

Most recent registration

State/Territory/Country

Profession

Period of registration

D D / M M / Y Y Y Y to D D / M M / Y Y Y Y

Additional registration

State/Territory/Country

Profession

Period of registration

D D / M M / Y Y Y Y to D D / M M / Y Y Y Y

You must arrange for original Certificates of Registration Status or Certificates of Good Standing to be forwarded directly from the registration authority to your AHPRA state office. Refer to www.ahpra.gov.au/About-AHPRA/Contact-Us for your AHPRA state office address.

Attach a separate sheet if your registration history does not fit in the space provided.

SECTION H: Work history

12. What is your full practice history?

It is important that you refer to Curriculum vitae in the Information and definitions section of this form for mandatory requirements of the CV. Your curriculum vitae will further inform the Board in relation to your recency of practice and registration history.

You must attach to your application a signed and dated curriculum vitae that describes your full practice history and any clinical or skills training undertaken.

SECTION I: Suitability statements

Information required by the Board to assess your suitability for registration is detailed in the following questions. It is recommended that you provide as much information as possible to enable the Board to reach a timely and informed decision.Please note that registration is dependent on suitability as defined in the National Law, and the requirements set out in the Board’s registration standards. Refer to www.medicalboard.gov.au/Registration-Standards for further information.

13. Do you have any criminal history in Australia?

It is important that you have a clear understanding of the definition of criminal history. For more information, see Criminal history in the Information and definitions section of this form.

YES NO

Provide a separate sheet with details of your criminal history in Australia and explanation of circumstances.

14. Do you have any criminal history in another country?

For more information, see Criminal history in the Information and definitions section of this form.

YES NO

Provide a separate sheet with details of your criminal history in another country and explanation of circumstances.

15. Have you previously been registered to practise as a medical practitioner in Australia?

If you have previously been registered to practise as a medical practitioner in Australia, you have met the requirements of the Board’s English language skills registration standard. However, the Board may still require you to provide evidence of your English language skills. In such a case, the Board will contact you.

YES Go to question 19 NO Go to the next question

*AGSP-307*AGSP-30


16. Did you undertake and complete your secondary education and your tertiary qualifications in the profession, in English, in one of the countries listed?

For more information see English language skills in the Information and definitions section of this form.

• Australia •Canada •NewZealand •RepublicofIreland •SouthAfrica •UnitedKingdom •UnitedStatesofAmerica

YES NO Go to the next question

Attachment required below – then go to question 19

You must submit a certified copy of the original evidence of having undertaken your secondary education in English.

17. Which of these English language examinations have you successfully completed?

Pass result must be obtained in one sitting.

International English Language Test System (IELTS) Academic module Test report form number:

The Board requires an IELTS Academic module score of at least 7 in each of the four components (listening, reading, writing and speaking).

Occupational English Test (OET) Candidate number:

- - The Board requires completion and an overall pass in the OET, with grades A or B in each of the four components (listening, reading, writing and speaking).

Professional and Linguistic Assessment Board (PLAB) Part 2

New Zealand Registration Exam (NZREX)

You must attach a certified copy of your Board-approved English language test result.

18. Were your results from the above-mentioned English language examinations obtained within two years of applying for registration?

For more information, see English language skills in the Information and definitions section of this form.

YES NO

You must attach evidence that you have actively maintained employment as a registered health practitioner, or been continuously enrolled as a student in an approved program of study, using English as the primary language of practice in one of the following countries:

• Australia• Canada • New Zealand• Republic of Ireland

• South Africa• United Kingdom• United States of America

19. Do you commit to having appropriate professional indemnity insurance arrangements in place for all practice undertaken during the registration period?

For more information, see Professional indemnity insurance in the Information and definitions section of this form.

YES NO

20. Are you returning from a temporary absence from practice?

YES NO Go to question 25

Choose the appropriate option

More than 12 months Go to the next question

Less than 12 months Go to question 24

21. Did you previously practise medicine for more than two years?

For more information, see Practice in the Information and definitions section of this form.

YES NO

You are required to commence work under supervision in a training position approved by the Board. You must attach details of the supervised training position you propose to take up.

*AGSP-308*AGSP-30


22. How long have you been absent from practice?

For more information on returning to practice and the template for Plan for professional development and re-entry to practice, see www.medicalboard.gov.au/Codes-Guidelines-Policies/FAQ

Choose the appropriate option

Between one and three years

You must attach evidence of having completed the required pro rata continuing professional development.

More than three years

You must attach a plan for professional development and for re-entry to practice for consideration by the Board.

23. Will you be changing your scope of practice since you were last practising?

YES NO

You must attach details, including any relevant training and assessments undertaken, for the Board to consider your application.

24. Have you changed the scope of your practice in the previous 12 months?

YES NO

You must attach details, including any relevant training and assessments undertaken, for the Board to consider your application.

25. Do you have an impairment that detrimentally affects, or is likely to detrimentally affect, your capacity to practise the profession?

For more information, see Impairment in the Information and definitions section of this form.

YES NO

You must attach to this application details of any impairments and how they are managed.

26. Is your registration in any profession currently suspended or cancelled in Australia (under the National Law or a corresponding prior Act) or overseas?

YES NO

You must attach to this application details of any registration suspension or cancellation.

27. Have you previously had your registration cancelled, refused or suspended in Australia (under the National Law or a corresponding prior Act) or overseas?

YES NO

You must attach to this application details of any cancellation or refusal.

28. Has your registration ever been subject to conditions, undertakings or limitations in Australia (under the National Law or a corresponding prior Act) or overseas?

YES NO

You must attach to this application details of any conditions, undertakings or limitations.

29. Are you disqualified from applying for registration, or being registered, in any profession in Australia (under the National Law, a corresponding prior Act or a law of a co-regulatory jurisdiction), or overseas?

Co-regulatory jurisdiction means a participating jurisdiction (of the National Law) in which the Act applying (the National Law) declares that the jurisdiction is not participating in the health, performance and conduct process provided by Divisions 3 to 12 of Part 8 (of the National Law).

YES NO

You must attach to this application details of any disqualifications.

*AGSP-309*AGSP-30


30. Have you been, or are you currently, the subject of conduct, performance or health proceedings whilst registered under the National Law, a corresponding prior Act, or the law of another jurisdiction in Australia or overseas, where those proceedings were not finalised?

YES NO

You must attach to this application details of any conduct, performance or health proceedings.

SECTION J: Obligations and consent Before you sign and date this form, make sure that you have answered all of the relevant questions correctly and read the statements below.

An incomplete form may delay processing and you may be asked to complete a new form. For more information, see the Information and definitions section of this form.

Obligations of registered health practitioners The National Law pt 7 div 11 sub-div 3 establishes the legislative obligations of registered health practitioners. A contravention of these obligations, as detailed at points 1, 2, 4, 5, 6 or 8 below does not constitute an offence but may constitute behaviour for which health, conduct or performance action may be taken by the Board. Registered health practitioners are also obligated to meet the requirements of their Board as established in registration standards, codes and guidelines.Continuing professional development1. A registered health practitioner must undertake the continuing professional

development required by an approved registration standard for the health profession in which the practitioner is registered.

Professional indemnity insurance arrangements2. A registered health practitioner must not practise the health profession in which

the practitioner is registered unless appropriate professional indemnity insurance arrangements are in force in relation to the practitioner’s practice of the profession.

3. A National Board may, at any time by written notice, require a registered health practitioner registered by the Board to give the Board evidence of the appropriate professional indemnity insurance arrangements that are in force in relation to the practitioner’s practice of the profession.

4. A registered health practitioner must not, without reasonable excuse, fail to comply with a written notice given to the practitioner under point 3 above.

Notice of certain events5. A registered health practitioner must, within 7 days after becoming aware that a

relevant event has occurred in relation to the practitioner, give the National Board that registered the practitioner written notice of the event. Relevant event means—a) the practitioner is charged, whether in a participating jurisdiction or elsewhere,

with an offence punishable by 12 months imprisonment or more; orb) the practitioner is convicted of or the subject of a finding of guilt for an

offence, whether in a participating jurisdiction or elsewhere, punishable by imprisonment; or

c) appropriate professional indemnity insurance arrangements are no longer in place in relation to the practitioner’s practice of the profession; or

d) the practitioner’s right to practise at a hospital or another facility at which health services are provided is withdrawn or restricted because of the practitioner’s conduct, professional performance or health; or

e) the practitioner’s billing privileges are withdrawn or restricted under the Human Services (Medicare) Act 1973 (Cth) because of the practitioner’s conduct, professional performance or health; or

f) the practitioner’s authority under a law of a State or Territory to administer, obtain, possess, prescribe, sell, supply or use a scheduled medicine or class of scheduled medicines is cancelled or restricted; or

g) a complaint is made about the practitioner to the following entities—(i) the chief executive officer under the Human Services (Medicare) Act 1973

(Cth);(ii) an entity performing functions under the Health Insurance Act 1973 (Cth);(iii) the Secretary within the meaning of the National Health Act 1953 (Cth);(iv) the Secretary to the Department in which the Migration Act 1958 (Cth) is

administered;(v) another Commonwealth, State or Territory entity having functions relating

to professional services provided by health practitioners or the regulation of health practitioners.

h) the practitioner’s registration under the law of another country that provides for the registration of health practitioners is suspended or cancelled or made subject to a condition or another restriction.

Change in principal place of practice, address or name6. A registered health practitioner must, within 30 days of any of the following changes

happening, give the National Board that registered the practitioner written notice of the change and any evidence providing proof of the change required by the Board—a) a change in the practitioner’s principal place of practice;b) a change in the address provided by the registered health practitioner as the

address the Board should use in corresponding with the practitioner;c) a change in the practitioner’s name.

Employer’s details7. A National Board may, at any time by written notice given to a health practitioner

registered by the Board, ask the practitioner to give the Board the following information—a) information about whether the practitioner is employed by another entity;b) if the practitioner is employed by another entity—

(i) the name of the practitioner’s employer; and(ii) the address and other contact details of the practitioner’s employer.

8. The registered health practitioner must not, without reasonable excuse, fail to comply with the notice.

ConsentI consent to the Board and AHPRA making enquiries of, and exchanging information with, the authorities of any Australian state or territory, or other country, regarding my practice as a health practitioner or otherwise regarding matters relevant to this application.I authorise the Board to obtain my criminal history in Australia and overseas. I understand that: • a complete criminal history, including resolved and unresolved charges, spent

convictions, and findings of guilt for which no conviction was recorded, will be released to the Board, and

• information will be extracted from this form and used for the purpose of criminal history checking. This information may be used by Australian police services for law enforcement purposes including the investigation of any outstanding criminal offences.

I acknowledge that:• the Board may validate documents provided in support of this application as

evidence of my identity, and• failure to complete all relevant sections of this application and to enclose all

supporting documentation may result in this application not being accepted. I undertake to comply with all relevant legislation and Board registration standards, codes and guidelines. I understand that personal information that I provide may be given to a third party for regulatory purposes, as authorised or required by the National Law.I understand AHPRA may:• disclose the date my registration is to commence and future registration details; and• verify the accuracy of my registration details including my date of birth and address

to entities (such as prospective employers) who disclose that information to AHPRA for the purpose of confirming my identity.

AHPRA will only do this where the entity seeking the information or verification has given a legal undertaking they have obtained my consent to these disclosures and this verification.I declare that:• the above statements, and the documents provided in support of this application,

are true and correct, and• I am the person named in the attached documents.I make this declaration in the knowledge that a false statement is grounds for the Board to refuse registration.

Signature of applicant

SIGN HEREName of applicant

Date

D D / M M / Y Y Y Y

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Third party to act on behalf of applicant – To be completed and signed by the applicant and agent

Under the Privacy Act 1988 (Cth), the Board is generally not permitted to disclose personal information about an applicant to a third party. An applicant may authorise a third party (agent) to communicate with the Board and/or act on behalf of the applicant, by completing the following details.

31. Do you wish to appoint an agent to communicate/act on your behalf in relation to this application?

An agent can be an employer, sponsor, recruitment agent or any other individual authorised by the applicant to act on their behalf in relation to this application.

YES Complete applicant authorisation and arrange for agent to complete agent authorisation

NO

Applicant authorisationI authorise my agent to (mark one or more as required):

communicate with the Board on my behalf regarding the processing and progress of my application. (The agent and the Board may communicate by telephone, fax, email or written correspondence)

undertake any other action reasonably necessary for the processing of my application on my behalf (except signing and lodging applications forms, which must be completed by the applicant), and

receive all formal correspondence from the Board in relation to this application.

Date

D D / M M / Y Y Y YSignature of applicant

SIGN HERE

Agent authorisationAGENT TO COMPLETE: I consent to act as agent of the registrant named below.

Full name of agent

Full name of applicant

Agent contact detailsAddress/PO Box (e.g. 123 JAMES AVENUE; or UNIT 1A, 30 JAMES STREET; or PO BOX 1234)

City/Suburb/Town

State or territory (e.g. VIC, ACT)/International province Postcode/ZIP

Country

Business hours

Mobile

Email

Date

D D / M M / Y Y Y YSignature of agent

SIGN HERE

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Credit/Debit card payment slip – please fill out

Amount payable

$ Visa or MasterCard number

Expiry date

M M / Y Y

Name on card

Cardholder’s signature

SIGN HERE

SECTIONK:Payment

You are required to pay both an application fee and a registration fee.

Your required payment is detailed below: Use the table below to select your application fee and registration fee. Your registration fee depends on your principal place of practice, as applicants whose principal place of practice is New South Wales are entitled to a rebate from the NSW Government.

Application fee: Registration fee: Amount payable:

$695 + $ INSERT FEE = $ INSERT FEERegistration fee $695 Applicants must pay 100% of the stated fees

at the time of submitting the application. Registration fee for NSW registrants $612

Registration period The annual registration period for the medical profession is from 1 October to 30 September. If your application is made between 1 August and 30 September this year, you will be registered until 30 September next year.

Refund rules The application fee is non-refundable. The registration fee will be refunded if the application is not approved.

32. How are you paying your fees? Payment by cheque, money order or bank draft must be in Australian currency, drawn on an Australian bank. A receipt will be posted.

Mark one box below only

Visa or MasterCard Cash/EFTPOS Complete credit/debit card payment slip below (only available if paying in person)

Cheque/Money order/Bank draft

You must attach your cheque, money order or bank draft payable to the Australian Health Practitioner Regulation Agency.

On the back of the cheque, money order or bank draft, you must write:• your full name• your date of birth, and • your AHPRA registration number (if you have one).

*AGSP-3012*AGSP-30


SECTION L: Checklist

Have the following items been attached or arranged, if required?

Additional documentation Attached

Question 1 Evidence of a change of name

Question 3 Certified copies of all documents that provide sufficient evidence of your identity

Question 8 Certified copies of all of your relevant academic qualifications

Question 10 Evidence of completion of your internship or comparable

Question 11 Certificate of Registration Status or Certificate of Good Standing has been requested from relevant authority

Question 11 A separate sheet with registration details

Question 12 Your curriculum vitae

Question 13 A separate sheet with an explanation of circumstances of your criminal history in Australia

Question 14 A separate sheet with an explanation of circumstances of your criminal history overseas

Question 16 Evidence of the successful completion of an approved English language test has been requested from relevant authority

Question 17 A certified copy of your Board-approved English language test result

Question 18 Evidence that you have actively maintained employment or study using English as the primary language of practice

Question 21 Details of the training position you propose to take up

Question 22 Evidence of having completed the required pro rata continuing professional development

Question 22 A plan for professional development and for re-entry to practice

Questions 23+24 Details of the training and assessments

Question 25 A separate sheet with your impairment details

Question 26 A separate sheet with your current suspension or cancellation details

Question 27 A separate sheet with your suspension, cancellation or refusal details

Question 28 A separate sheet with your conditions, undertakings or limitations details

Question 29 A separate sheet with your disqualification details

Question 30 A separate sheet with your conduct, performance or health proceedings

Payment

Application fee

Registration fee

If paying by cheque/money order/bank draft, your name is written on the back

Please post this form with payment and required attachments to:

AHPRA GPO Box 9958IN YOUR CAPITAL CITY (refer below)

You may contact AHPRA on 1300 419 495 or you can lodge an enquiry at www.ahpra.gov.au

Sydney NSW 2001 Canberra ACT 2601 Melbourne VIC 3001 Brisbane QLD 4001

Adelaide SA 5001 Perth WA 6001 Hobart TAS 7001 Darwin NT 0801

*AGSP-3013*AGSP-30


Information and definitionsCERTIFYING DOCUMENTSDO NOT send original documents unless specified. Copies of documents provided in support of an application, or other purpose required by the National Law, must be certified as true copies of the original documents. Each and every certified document must:• be in English. If original documents are not in English, you must provide a

certified copy of the original document and translation in accordance with AHPRA guidelines, which are available at www.ahpra.gov.au/registration/registration-process

• be initialled on every page by the authorised officer. For a list of people authorised to certify documents, visit www.ahpra.gov.au/certify

• be annotated on the last page as appropriate e.g. ‘I have sighted the original document and certify this to be a true copy of the original’ and signed by the authorised officer, and

• list the name, date of certification, and contact phone number, and position number (if relevant) and have the stamp or seal of the authorised officer (if relevant) applied.

Certified copies will only be accepted in hard copy by mail or in person (not by fax, email, etc). Photocopies of previously certified documents will not be accepted. For more information, AHPRA’s guidelines for certifying documents can be found online at www.ahpra.gov.au/certify

CHANGE OF NAMEYou must provide evidence of a change of name if you have ever been formally known by another name(s) or any of the documentation you are providing in support of your application is in another name(s).Evidence must be a certified copy of one of the following documents:• Standard marriage certificate (ceremonial certificates will not be accepted).• Deed poll.• Change of name certificate.Faxed, scanned or emailed copies of certified documents will not be accepted.

CONTINUING PROFESSIONAL DEVELOPMENT (CPD)You must participate regularly in continuing professional development (CPD) relevant to your scope of practice. CPD must include a range of activities to meet your individual learning needs, including practice-based reflective elements, such as clinical audit, peer-review or performance appraisal, as well as participation in activities to enhance knowledge such as courses, conferences and online learning. CPD programs of medical colleges accredited by the Australian Medical Council meet these requirements. Refer to the Board’s Continuing professional development registration standard for details of the requirements which relate to your situation. For more information, view the full registration standard online at www.medicalboard.gov.au/Registration-Standards

CRIMINAL HISTORYCriminal history includes the following, whether in Australia or overseas, at any time:• every conviction of a person for an offence• every plea of guilty or finding of guilt by a court of the person for an

offence, whether or not a conviction is recorded for the offence, and• every charge made against the person for an offence.Under the National Law, spent convictions legislation does not apply to criminal history disclosure requirements. Therefore, you must disclose your complete criminal history as detailed above, irrespective of the time that has lapsed since the charge was laid or the finding of guilt was made. The Board will decide whether a health practitioner’s criminal history is relevant to the practice of the profession.Do not provide copies of a criminal history check. AHPRA will conduct a check on your behalf.For more information, view the full registration standard online at www.medicalboard.gov.au/Registration-Standards

CURRICULUM VITAEYour curriculum vitae must:• explain any period since obtaining your professional qualifications where

you have not practised and reasons why (e.g. undertaking study, travel, family commitment)

• be in chronological order• be signed and dated with a statement, ‘This curriculum vitae is true and

correct as at (insert date)’, and• be the original signed curriculum vitae (no faxes or scanned copies

will be accepted).It must also contain all the elements defined in AHPRA’s standard format for curriculum vitae which can be found at www.ahpra.gov.au/cv

ENGLISHLANGUAGESKILLS To be eligible for registration you must be able to provide evidence of English language skills that meet the Board’s English language skills registration standard which can be found at www.medicalboard.gov.au/Registration-Standards

IMPAIRMENTImpairment means a physical or mental impairment, disability, condition, or disorder (including substance abuse or dependence) that detrimentally affects or is likely to detrimentally affect your capacity to practise the profession. The National Law requires you to declare any such impairments at the time of renewal, including details of the impairment and how it is managed.

PRACTICEPractice means any role, whether remunerated or not, in which you use your skills and knowledge as a health practitioner in your profession. Practice is not restricted to the provision of direct clinical care. It also includes using professional knowledge in a direct non-clinical relationship with clients, working in management, administration, education, research, advisory, regulatory or policy development roles and any other roles that impact on safe, effective delivery of services in the profession.

PROFESSIONAL INDEMNITY INSURANCE (PII)You must have professional indemnity insurance (PII), or some alternative form of indemnity cover that complies with the Board’s standard, for all aspects of your medical practice. Initial registration and annual renewal of registration requires a declaration that you will be covered for all aspects of practice for the whole period of the registration. You may be covered by your Australian employer’s PII – you will need to confirm this with your employer.Where the scope of medical practice of an individual medical practitioner does not include the provision of healthcare or medical opinion in respect to the physical or mental health of any person, PII is not required for the purposes of registration. For more information, view the full registration standard online at www.medicalboard.gov.au/Registration-Standards

RECENCY OF PRACTICETo ensure that you can practise competently and safely, you must have recent practice in the field in which you intend to work during the period of registration for which you are applying.The specific requirements for recency depend on the field of practice, your level of experience and the length of absence from the field.If you propose to change your field of practice, the Board will consider whether your peers would view the change as a normal extension or variation in a field of practice, or a change that would require specific training and demonstration of competence. Practitioners who are unable to meet recency of practice requirements must submit a plan for re-entry to practice for the Board’s consideration and may be required to complete specific education. For more information, view the full registration standard online at www.medicalboard.gov.au/Registration-Standards

agsp-30 - application for registration as a medical ... · pdf fileagsp-30 *agsp-303*...

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agsp-30 - application for registration as a medical ... · pdf fileagsp-30 agsp-303...